by Dr. Mark Gold
“Sadness typically arises,” Dorison et al. wrote late last year, “from experiences of irrevocable loss.”(1) To many, it’s just intuitive that our emotions play an important role in the choices we make, helping to govern everything from what we want to eat to whether we feel like exercising to the music we want to hear or television we want to watch. Our emotions are like the delicate engines of old cars, misfiring or charmingly humming or roaring us along on a journey. But we don’t like to make this connection about sadness. Sadness is different, because it makes us think about ourselves, which makes us want rewards to replace our loss. And that might be why it contributes to addiction.
Researchers have long considered the paradox that substances produce highs, yet those with substance use disorders (SUD) are often sad, depressed, and at times suicidal. Cocaine use previously stood out for this reason—a drug so associated with energy led to anhedonia, depression, lethargy, and dopamine depletion in individuals using it.(2) Alcohol Use Disorders are often accompanied by feelings of helplessness, sadness, depression, and suicidal thoughts. These patients often use alcohol and tobacco, offering little relief from depression, and two SUDs to treat.(3) Cigarette smokers themselves are often depressed and, more recently, we’ve learned that living in a household with exposure to secondhand smoke causes depression.(4) Individuals using cannabis are also often depressed, and there’s some recent evidence of an association with suicidal thinking in younger individuals using cannabis.(5) Substance use starts high and ends low, in depression and even despair.(6),(7) The COVID-19 pandemic, through its inundation of pain, its deaths and job losses and isolation, breeds generalized sadness—and puts individuals with SUD at higher risk.
There’s now more research confirming our intuitions about how emotions can influence our behavior, pushing us to danger and safety in powerful and identifiable ways.8 As the science has advanced, it’s shown us that we’ll get a better idea of behavioral influence by looking at particular emotions instead of general moods, at, say, sadness and anger, instead of broadly “positive” or “negative” states. But these findings haven’t focused on emotions influencing behaviors linked to worse health, including ones that can lead to addiction. Dorison et al., a team of Harvard researchers, set out to remedy this by testing the effects of sadness on tobacco use.
What did this study find about sadness and smoking?
This study found that sadness, not other negative emotions, increases tobacco use. Dorison et al., chose tobacco use as something of a rough proxy for “addictive substance use”—because it’s a legal substance, you can study use in a lab, and it is the leading cause of preventable death. This study looked at sadness because of its associations with reward-seeking, the way we try to replace an irrevocable loss by finding something else. It notes, for example, that research suggests we’ll spend more when we’re sad. “Self-focus,” the added attention we pay to ourselves when sad, might connect sadness and reward-seeking. This study set up a series of experiments to test the effects of sadness on smoking.
First, Dorison et al. looked at survey data on over 10,000 people, covering 1995-2014. They compared reported tobacco use to emotions, looking at questions like, “during the past 30 days, how often did you feel so sad nothing could cheer you up?”, with respondents answering on a 5-point scale. This study also looked at shame, fear, and anger, and controlled for socioeconomic status, gender, and age. It found that sadness did predict reported tobacco use, along with future use and recurrence of use, but shame, fear, and anger didn’t. Next, Dorison et al. tested the role of sadness in cravings. They had 425 individuals who use tobacco divide into 3 groups: the sad, the disgusted, and the neutral. They tried to stimulate these emotions in each group by having them watch a film clip and write a reflection after. The sad watched a scene from the film Up, with a man whose wife dies; the disgusted watched a scene from Trainspotting, when someone uses a gross toilet; and the neutral watched a clip about making wooden furniture. Dorison et al. asked the three groups about their cravings after, and found that the sad, but not the disgusted, had more.
In a follow-up with another group, this study found that participants did not want to delay the time it took to use tobacco again, even though delay meant receiving other benefits. Dorison et al. then recruited 158 more individuals who use tobacco and had them watch the same video clips to again stimulate emotions, and gauged their interest in delaying tobacco use. Participants then completed a questionnaire to find whether sadness led to a sense of loss, general negativity, or self-focus. Self-focus, not loss or negativity, predicted desire to use tobacco quickly.
Why is this important?
SUDs aren’t driven by any one factor. The more we understand about different influences on the disease, the better off we’ll be in terms of treatment and prevention—especially if we understand more about the underlying processes of different influences. This study is important because it applies recent advances in modeling emotional influence over behaviors to addiction-related behaviors, and finds that we should guard against the dangers of sadness, in particular, because of its links to reward-seeking as we turn inwards and focus on ourselves. This is especially important now, as most public health experts warn of an epidemic of sadness, PTSD, depression, anxiety, and suicide in the wake of the pandemic. There are healthy ways to process sadness; therapy is a good start. We should practice self-care, eat well, exercise, and follow habits that may decrease the risk of developing an SUD.9 Dorison et al.’s study is also a good reminder of the importance of positive psychology and an optimistic outlook.
Dorison et al. also caution against reading too much into their work, given limited sample sizes in some of the research phases and the need for more studies on self-focus as a possible mechanism related to sadness. And while the study uses tobacco use as something of a stand-in for addictive substance use, the authors say that it would be “unwise” to consider the findings on sadness as a fit for other addictive substances. They also caution, “The present research does not hypothesize that sadness is unique among negative emotions in triggering addictive substance use.” Instead, they say, it’s a more powerful emotion in influencing substance use. There’s a nuance to our sadness, chills and hauntings unique to the details and memories of our particular irrevocable losses. The details are powerful just the same. They can drive us to darker places still.
Dorison, C. A., Wang, K., Rees, V. W., Kawachi, I., Ericson, K. M. M., & Lerner, J. S. (2019b). Sadness, but not all negative emotions, heightens addictive substance use. Proceedings of the National Academy of Sciences, 117(2), 943–949. https://doi.org/10.1073/pnas.1909888116
Dackis, C. A., & Gold, M. S. (1985). New concepts in cocaine addiction: The dopamine depletion hypothesis. Neuroscience & Biobehavioral Reviews, 9(3), 469–477. https://doi.org/10.1016/0149-7634(85)90022-3
Epstein, J.F., Induni, M., Wilson, T. (2009). Patterns of clinically significant symptoms of depression among heavy users of alcohol and cigarettes. Blah blah, 6(1), A09
Milic, M., Gazibara, T., Pekmezovic, T., Kisic Tepavcevic, D., Maric, G., Popovic, A., … Levine, H. (2020). Tobacco smoking and health-related quality of life among university students: Mediating effect of depression. PLOS ONE, 15(1), e0227042. https://doi.org/10.1371/journal.pone.0227042
Gobbi, G., Atkin, T., Zytynski, T., Wang, S., Askari, S., Boruff, J., … Mayo, N. (2019). Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and Suicidality in Young Adulthood. JAMA Psychiatry, 76(4), 426. https://doi.org/10.1001/jamapsychiatry.2018.4500
Grant, B. F. (1995). Comorbidity between DSM-IV drug use disorders and major depression: Results of a national survey of adults. Journal of Substance Abuse, 7(4), 481–497. https://doi.org/10.1016/0899-3289(95)90017-9
Jacob, L., Smith, L., Jackson, S. E., Haro, J. M., Shin, J. I., & Koyanagi, A. (2020). Secondhand Smoking and Depressive Symptoms Among In-School Adolescents. American Journal of Preventive Medicine. https://doi.org/10.1016/j.amepre.2019.12.008
Lerner, J. S., Li, Y., Valdesolo, P., & Kassam, K. S. (2015). Emotion and Decision Making. Annual Review of Psychology, 66(1), 799–823. https://doi.org/10.1146/annurev-psych-010213-115043